Provider Demographics
NPI:1417028135
Name:DIXIE REST HOME 1
Entity Type:Organization
Organization Name:DIXIE REST HOME 1
Other - Org Name:WOODHAVEN REST HOME 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:252-445-5665
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:310 NORTH MARTIN LUTHER KING AVENUE
Mailing Address - City:ENFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27823
Mailing Address - Country:US
Mailing Address - Phone:252-445-5665
Mailing Address - Fax:252-445-3466
Practice Address - Street 1:310 NORTH MARTIN LUTHER KING AVENUE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:NC
Practice Address - Zip Code:27823
Practice Address - Country:US
Practice Address - Phone:252-445-5665
Practice Address - Fax:252-445-3466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL042002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801459Medicaid